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Journal of Learning Disabilities

Spelling Difficulties in School-Aged Girls 2014, Vol. 47(5) 424­–434

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DOI: 10.1177/0022219412467058
journaloflearningdisabilities
Disorder: Behavioral, Psycholinguistic, .sagepub.com

Cognitive, and Graphomotor Correlates

Jakob Åsberg Johnels, PhD,1 Svenny Kopp, PhD, MD,1

and Christopher Gillberg, PhD, MD1

Abstract
Writing difficulties are common among children with attention-deficit/hyperactivity disorder (ADHD), but the nature of
these difficulties has not been well studied. Here we relate behavioral, psycholinguistic, cognitive (memory/executive), and
graphomotor measures to spelling skills in school-age girls with ADHD (n = 30) and an age-matched group of typically
developed spellers (TYPSP, n = 35). When subdividing the ADHD group into those with poor (ADHDPSP, n = 19) and
typical spelling (ADHDTYPSP, n = 11), the two subgroups did not differ with regard to inattentive or hyperactive–impulsive
symptom severity according to parent or teacher ratings. Both ADHD subgroups also had equally severe difficulties in
graphomotor control–handwriting and (parent ratings of) written expression as compared to the TYPSP group. In contrast,
ADHDPSP had problems relative to ADHDTYPSP and TYPSP on phonological and orthographic recoding (choice tasks) and
verbal memory (digit span) and were more likely to make commissions on a continuous performance task (CPT). Further
analyses using the collapsed ADHD group showed that both digit span and the presence of CPT commissions predicted
spelling performance independently of each other. Finally, results showed that phonological recoding skills mediated the
association between digit span and spelling performance in ADHD. Theoretical and educational implications are discussed.

Keywords
writing, literacy, ADHD, girls, memory, executive functions, handwriting

Attention-deficit/hyperactivity disorder (ADHD) is charac-
terized by elevated levels of inattention and/or hyperactivity–
impulsivity that often impede severely on academic and
social functioning. The prevalence of ADHD is approxi-
mately 3% to 7% among children. The boy to girl ratio of
ADHD prevalence is still uncertain, and estimates range
between 2:1 and 9:1 in the literature, depending on ADHD
subtype and setting (APA, 2000). The gender ratio differ-
ence is greater in clinical than in school-based samples,
suggesting that girls are less likely to be referred for ADHD-
related problems (Biederman & Faraone, 2005; Gaub &
Carlson, 1997).
Research has shown that ADHD often is associated with
reading difficulties (e.g., Barkley, 1997; Mayes & Calhoun,
2006, 2007). Also, writing difficulties, although consider-
ably less studied, appear common in school-aged children
with ADHD, and this seems to hold true in both population-
based and clinical samples (Mayes & Calhoun, 2006,
2007; Yoshimasu et al., 2011), across both genders
(Yoshimasu et al., 2011), and across different orthographies
and countries (although, to date, mostly English-speaking
children have been studied; cf. Casas, Ferrer, & Fortea, in
press, for a recent Spanish study).
Reading and writing are two closely related skills; how-
ever, they are not one and the same ability, and it has been
shown that word decoding and spelling can dissociate (Moll
& Landerl, 2009; Tainturier, Valdois, David, Leek, & Pellat,
2002). Not being able to write adequately puts a child in a
disadvantaged position. In school, writing is ideally used
both as a means for exploring and organizing one’s ideas in
different content areas and for showing what you know to the
teacher and other students. It is further known that although
some children with poor literacy skills eventually overcome
their word reading problems, difficulties in spelling tend to
1
University of Gothenburg, Gothenburg, Sweden
Corresponding Author:
Jakob Åsberg Johnels, Gillberg Neuropsychiatry Centre, University of
Gothenburg, Kungsgatan 12, SE-411 19 Göteborg, Sweden.
Email: psyjaas@psy.gu.se
Åsberg Johnels et al.
persist into adulthood (e.g., Høien & Lundberg, 2000; cf.
Maughan et al., 2009). It is therefore important to specifi-
cally understand the nature and correlates of spelling and
writing skills or disabilities.
Context and Overall Aims
of the Present Study
As part of a large-scale Swedish research project on neuro-
developmental disorders in girls (Kopp, Beckung, &
Gillberg, 2010; Kopp, Berg-Kelly, & Gillberg, 2010; Kopp
& Gillberg, 2011), we have previously reported data on lit-
eracy skills in girls with ADHD (Åsberg, Kopp, Berg-Kelly,
& Gillberg, 2010). In that study an overall lower spelling
performance in the ADHD group was found relative to
norms and a typically developed comparison group, thereby
mirroring the results of previous research in male or mixed-
sex samples (e.g., Mayes & Calhoun, 2006). In this new
study from the same project, the aim was to examine cor-
relates of poor and typical spelling in girls with ADHD. For
this purpose, we initially subdivided the participants with
ADHD into a poor spellers group and a typical spellers
group. These groups were then compared to each other and
to a comparison group of typical spellers without ADHD on
a number of critical skills discussed below. Once potential
key variables were identified, close-up analyses were also
conducted within the collapsed group with ADHD. A num-
ber of questions and hypotheses were addressed based on
(a) existing knowledge of the complex, multifactorially
determined (cognitive and behavioral) phenotype in ADHD
and (b) existing knowledge of spelling as a complex and
“layered” psycho-motor-linguistic skill.
First, we examined whether spelling skills were associated
with severity level of ADHD-related symptoms. Behavioral-
cognitive (e.g., Willcutt & Pennington, 2000) and behavioral-
genetic (e.g., Willcutt, Pennington, & DeFries, 2000)
research has shown that academic skill difficulties appear
more closely related to the inattentive than the hyperactive–
impulsive dimension in ADHD. We therefore first asked
whether poor spelling was associated with increasing severity
of ADHD symptoms according to parent and teacher ratings
and expected to see an association between poor spelling per-
formance and more severe behavioral inattentiveness.
Second, we examined how spelling skills in ADHD were
associated with key variables within the lexical quality
hypothesis (cf. Perfetti & Hart, 2002). According to this
framework, literacy acquisition rests on a foundation of oral
language skills, and successful spelling acquisition entails the
setting up of associations among the orthographic, phono-
logical, and semantic aspects of words into “a common core
representation” (Perfetti & Hart, 2002, p. 190). Although the
general mechanism for building such representations might
be similar as in reading, spelling is considered “the purest
indicator of lexical quality” as it places much higher demands
425
on the precision of these representations (Perfetti, 1997, p. 30).
There is currently a strong research interest into the associa-
tions of these skills, on one hand, and reading or spelling per-
formance, on the other, in typically developing or dyslexic
samples (e.g., Deacon, Benere, & Castles, 2012; Mesman &
Kibby, 2011), although, to date, little is known in this regard
about spelling skills in ADHD. Yet given that a variety of
language-related impairments (including phonological and
semantic) are known to be common in school-aged children
with ADHD (Purvis & Tannock, 1997), and possibly espe-
cially so in girls with ADHD (Hinshaw, 2002; James &
Taylor, 1990), we predicted that poor spelling in ADHD
would be associated with poor performance on orthographic,
phonological, and semantic lexical tests.
Third, we analyzed how spelling performance was asso-
ciated with executive functions (cognitive speed, inhibition,
and attentiveness) and verbal memory span as assessed with
neuropsychological tests. Based on prior research we
expected to see more difficulties in these realms of cogni-
tive functioning among poor spellers with ADHD. Indeed, a
recent study by Semrud-Clikeman and Harder (2011) found
that problems in inhibition and other executive functions
predicted spelling and interpunctuation skills in a mixed
sample of students with and without ADHD. Furthermore,
there is a robust body of research linking poor verbal mem-
ory to spelling difficulties (e.g., Alloway, Gathercole, &
Elliott, 2010), also in samples diagnosed with ADHD
(Alloway et al., 2010; Korkman & Pesonen, 1994; Kroese,
Hynd, Knight, Hiemenz, & Hall, 2000). Critically, Korkman
and Pesonen (1994) found that poor spellers with ADHD
scored more poorly on a digit-span task as compared to
more skilled spellers with ADHD. This could be taken to
suggest that poor verbal memory skills, which sometimes
(but not always) are seen in ADHD, constrain spelling
development in this population.
The digit-span test in the Wechsler Intelligence Scale for
Children requires holding phonological units in the form of
digits in short-term memory and having conscious access for
manipulation of this material in the backward condition.
Whether such processing is independent, primary, or reflec-
tive of phonological functions is a matter of debate and
ongoing study in dyslexia research (cf. Beneventi, Tonnessen,
Ersland, & Hugdahl, 2010; Locascio, Mahone, Eason, &
Cutting, 2010; Ramus & Szenkovits, 2008), but has to our
knowledge not been examined closely in ADHD. In this
study we wished to test the hypothesis that the proposed
association between digit span and spelling in ADHD is
mediated by lexical phonological skills, meaning that the
ability to hold and manipulate verbal information in mem-
ory is an important correlate of the ability to phonologically
recode written words, and that this skill in turn predicts
spelling performance.
Fourth, we wanted to examine graphomotor control and
handwriting, as previous research has shown that often
426 Journal of Learning Disabilities 47(5)
these functions are challenging for many individuals with
ADHD (e.g., Adi-Japha et al., 2007; Racine, Majnemer,
Shevell, & Snider, 2008), and that automaticity in handwrit-
ing has been shown to predict variance in spelling perfor-
mance in community samples (cf. Berninger & Amtmann,
2003). This association between handwriting and spelling
abilities might possibly be interpreted within a “limited
capacity framework” of the writing process (McCutchen,
1996), wherein an impaired or dysfluent lower level skill
(such as handwriting) “steals” processing resources that oth-
erwise could have been used to executive higher level opera-
tions (such as spelling) with greater ease and accuracy.
Against this backdrop, we asked whether poor spelling in
girls with ADHD was associated with poor graphomotor
control and handwriting.
Our final aim was to address to what extent spelling skills
or difficulties are reflected in parent-reported abilities in
written expression and composition. As poor spelling ability
in individuals with dyslexia (without ADHD) has been
shown to predict poorer quality of written output (e.g., qual-
ity of sentences and essay construction; cf. Berninger,
Nielsen, Abbott, Wijsman, & Raskind, 2008), again presum-
ably because of the constraining of shared processing
resources between these sets of skills, it might be expected
that poor spellers with ADHD would present with poor writ-
ten expression skills. Yet the ability to express one’s thoughts
in writing is a highly complex skill, drawing on a range of
additional abilities such as planning, temporal organization,
and revision. These processes possibly are difficult for indi-
viduals with ADHD more generally, and Mayes and Calhoun
(2006) found that disorder of written expression was more
common than spelling disorder (63% vs. 25%) in their study
sample of students with ADHD. Hence, one possibility is
that students with ADHD and poor spelling have distinctive
difficulties in written expression. Alternatively, difficulties
in written expression might be common in ADHD irrespec-
tive of spelling skills.
Method
Participants and Group Assignment
The study group included 65 girls aged 10 to 16 years. Of
these, 19 were poor spellers with ADHD (ADHDPS), 11 were
typical spellers with ADHD (ADHDTYPSP), and 35 were
typically developing skilled spellers (TYPSP). All girls had
a full-scale IQ of at least 70 according to the third edition
of the Wechsler Intelligence Scale for Children (WISC-III;
Wechsler, 1992). None was on or had previously been on
medication for ADHD symptoms. All girls had participated in
a previous study by Åsberg et al. (2010). Relative to the sample
in that study (N = 110), the current study group did not include
the 20 girls with an autism spectrum disorder. Furthermore,
6 girls in the comparison group had low spelling test scores,
that is, standard scores less than 85 (see below). Hence, we
could not guarantee that these girls had typically developed
spelling skills, and therefore we decided to exclude them
from further study in the present context. Finally, a total of
19 girls lacked phonological and orthographic choice test
data and so were not included in the study.
The group with ADHD were clinically referred and assessed
by a clinical research team at the Child Neuropsychiatric Clinic
(CNC) in Gothenburg. TYPSP participants were selected from
a local pediatric outpatient clinic register in the Gothenburg
region (Mölnlycke) to be comparable in terms of age with the
clinic girls. According to interviews with parents and outpa-
tient registers, TYPSP girls were free from diagnosed neuro-
psychiatric and neurodevelopmental disorders or learning
disabilities. The TYPSP group was evaluated in the same
way and with the same instruments as the participants with
ADHD. For more information on the diagnostic process,
please see Kopp, Berg-Kelly, et al. (2010).
A standard score less than 85, that is, 1 standard deviation
below the mean, on a test of spelling ability was used as the
cutoff for poor versus skilled spelling. (For information
about tests and instruments see the Testing and Instruments
section.) This is a common cutoff for “difficulties” but is
rather liberal, and therefore we prefer to use the term poor
spellers rather than spelling disabled or the like to describe
participants scoring below this cutoff.
Testing and Instruments
Individual testing of literacy skills was done by the same
special educator at the clinic and took approximately 1.5 to
2 hours in total. Breaks were allowed as necessary.
Standardized tests were utilized. When separate norms for
boys and girls were available, the girl norms were used.
There was no single broad Swedish spelling test available
that spanned the age range represented in this study. Great
care was taken to create a test battery that was as internally
homogenous as possible in terms of construct validity, even
though this meant that the test stimuli had different “names”
depending on age.
Raw test scores were first converted into z scores, based
on the population means and standard deviations reported
in the test manuals for different ages. After this, z scores
were converted to standard scores based on the normative
mean of 100 and a standard deviation of 15, with a standard
score floor of 50.
Spelling. The spelling test Stavning (Rockberg & Johansson,
1994) was used for girls in Grades 3 to 6 (approx.
9–12 years old), whereas the LS Test (Johanson, 1992) was
used for older girls. Both tests measure the ability to spell a
target word presented in a sentence context. Parent ratings of
spelling were evaluated with Item 97 from the Five to Fifteen
(FTF) questionnaire (Kadesjö et al., 2004), which indexes
spelling difficulties (i.e., “difficulty spelling”). The full FTF
Åsberg Johnels et al.
questionnaire covers a child’s development in many domains,
for example, learning and behavioral difficulties. The FTF
subscales have sound psychometric properties (cf. Kadesjö
et al., 2004). FTF items are scored as 0, 1, or 2 for does not
apply, applies sometimes, or definitely applies, respectively.
ADHD symptoms. Ratings based on the fourth edition of
the Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 1994) for symptoms of
inattention (9 criteria) and hyperactivity–impulsivity (9 crite-
ria) were collected using the Conners’ Teacher Rating Scale–
Revised: Long Form (CTRS-R; Conners, Sitarenios, Parker,
& Epstein, 1998) and the FTF questionnaire (Kadesjö et al.,
2004), from teachers and parents respectively. The CTRS-R
items are scored as 0, 1, 2, or 3 for not true at all, just a little
true, pretty much true, or very much true, respectively.
Results are expressed in girl-specific T-scores. Results on
the FTF are expressed in raw scores.
Intellectual functioning. Performance IQ and verbal IQ
from WISC-III (Wechsler, 1992) were collected for all girls.
Most girls were tested at the CNC; however, in cases where
the girl recently had been exposed to WISC testing else-
where, the data were gathered from the clinic in question.
Orthographic and phonological recoding skills. To assess
lexical orthographic and phonological recoding skills sepa-
rately, norm-referenced choice tasks standardized in Swed-
ish children were used (Olofsson, 1994). On the orthographic
choice test, the child is presented with two plausible spell-
ings of a word and asked to select the correct one (e.g., rain
or rane). This task is not possible to solve through phono-
logical recoding. On the phonological test, the child is pre-
sented with written words on a row and asked to select the
one that sounds like a real word, with some words being
nonwords (e.g., slirp) and one being a pseudohomophone
that sounds like a real word if read out aloud (e.g., kar). This
task is not possible to solve through orthographic recoding.
The number of correctly solved tasks in 2 minutes is sum-
marized, and here the results are expressed in standard
scores calculated from the norm-referenced means and stan-
dard deviations reported in the manual. The Swedish tasks
are directly modeled after the English versions of ortho-
graphic and phonological choice (Olson, Kliegl, Davidson,
& Foltz, 1985); the validity of the Swedish tasks is described
in the manual by means of correlations with other literacy
measures. Furthermore, Gustafson, Samuelsson, Johansson,
and Wallmann (in press) recently reported a test–retest cor-
relation of r = .91 on the orthographic choice task.
Semantic skills. The Vocabulary subtest from WISC-III
was used. This subtest is a definitional task, and results are
expressed in scaled scores with a mean of 10 and standard
deviation of 3.
Digit span. The Digit Span subtest from WISC-III was
used. The Digit Span subtest contains a forward and back-
ward condition. However, as raw score data are not avail-
able for all participants, only the total score is analyzed
427
here. Results are expressed in scaled scores around a mean
of 10 and a standard deviation of 3.
Continuous performance test. We used a continuous perfor-
mance test (CPT) called Complex Reaction Time (CRT),
which originally was developed by Max Frisk (1999; see
also Gillberg, Frisk, Carlström, & Rasmussen, 1981; Nyberg,
Bohlin, Berlin, & Janols, 2003). The test takes 20 minutes in
total and involves evoking a choice response to a visual
stimulus. The mean reaction time, the number incorrect
responses (commissions), and the number of omissions were
computer recorded. Reaction time performance was coded
as normal (< 75th percentile) versus slow (> 75th percentile)
according to the norm-referenced procedure reported in
Frisk (1999). On CPT tests more generally, commissions
are assumed to reflect poor inhibition, whereas omissions
are assumed to reflect cognitive inattentiveness (cf. Bark-
ley, Edwards, Laneri, & Fletcher, 2001). The number of
omissions and commissions in our study approached floor
levels (see data for girls in Frisk, 1999, for a similar result),
with many scores of zero. We therefore chose to code per-
formance on these variables categorically, 0 (no omissions
or commissions) or 1 (presence of one or more omissions or
commissions).
Graphomotor control–handwriting. Following the proce-
dure by Mayes and Calhoun (2007), among many others,
the Coding subtest from WISC-III was used as a proxy for
graphomotor control during writing. The Coding subtest is
a pen-and-paper copying task, with results expressed in
scaled scores around a mean of 10 and a standard deviation
of 3. In addition, we included data from Item 98 from the
FTF questionnaire, where parents rated their daughter’s let-
ter formation and handwriting difficulties (i.e., “Has diffi-
culties with the shape of letters and to write neatly”). A
higher raw score indicates more difficulties.
Written expression. Data from Item 99 from the FTF ques-
tionnaire was used, where parents rated their daughter’s dif-
ficulties in written expression (i.e., “Difficulty formulating
him/herself in writing”). A higher raw score indicates more
difficulties.
Statistical Analyses
Significance level was set to a two-tailed p < .05. For diag-
nostic group comparisons, nonparametric tests were chosen
because of the small and unequal groups. Pairwise group
comparisons (Mann–Whitney U with the adjusted signifi-
cance level are reported) were used only if the overall
Kruskal–Wallis test was significant. For categorical data,
chi-square tests were used with the inclusion of adjusted
standardized residuals in the cells to identify major con-
tributors in the case of a significant result. Correlations
were tested with Pearson correlations. Regression analyses
were conducted using the enter method. Before performing
the regression analyses, we checked that the distribution of
428 Journal of Learning Disabilities 47(5)
Table 1. Description of Selection (spelling) and Background Data in Study Groups.
Measure ADHDPSP
n 19
Selection variable (M, SD)
Spelling, test standard score 67.01 (9.61)
Background variables (M, SD)
Spelling difficulties, parent ratings 1.47 (0.77)
Chronological age 13.76 (1.78)
Performance IQ (WISC-III) 97.58 (17.44)
Verbal IQ (WISC-III) 91.26 (13.34)
Note: WISC = Wechsler Intelligence Scale for Children.
the dependent variable—that is, the spelling score—did not
deviate from normality according to the Kolmogorov–
Smirnov test with Lilliefors correction (p = .17). Mediation
analysis was done as per the Sobel test. SPSS Statistics 19
for Mac was used for all analyses, except the Sobel test,
which was conducted on an interactive resource (http://
quantpsy.org/sobel/sobel.htm). It was decided a priori that
group comparisons were not covaried for any verbal IQ dif-
ferences as the Vocabulary subtest from the verbal scale
was used as analytical variable in the study.
Results
Spelling Scores and Background Data
Table 1 provides details of the variable used for group
assignment, that is, typical versus poor speller groups, and
some background data. The ADHDPSP group scored more
than two standard deviations below the normative mean on
the spelling test, and significantly lower than both
ADHDTYPSP and TYPSP (both ps < .001), who performed
normally in spelling and did not differ from each other (p >
.99). A significant difference between groups was also found
on parent ratings of spelling ability, with the ADHDPSP
having significantly higher ratings of spelling difficulties
than both ADHDTYPSP and TYPSP (both ps < .001), who
in turn did not differ statistically from each other (p > .99).
Furthermore, the three groups did not differ on WISC-III
performance IQ, but ADHDPSP scored lower than TYPSP
on the verbal IQ scale (p = .001).
Symptomatology and Behavior
Test data and overall statistical analyses are reported in
Table 2. The three groups differed for parent and teacher
ratings of inattention and hyperactivity–impulsivity, with
follow-up pairwise comparisons revealing that both groups
Group
ADHDTYPSP TYPSP Overall Group Comparison (χ2)
11 35
103.93 (11.25) 102.28 (8.93) 39.78, p < .001
0.09 (0.30) 0.14 (0.43) 35.91, p < .001
13.62 (1.98) 13.55 (1.86) 0.11, p = .94
99.00 (14.20) 106.11 (12.07) 3.30, p = .19
95.73 (14.71) 106.37 (11.91) 14.97, p = .001
with ADHD had equally high ratings (all ps > .99) and that
both ADHD groups had considerably higher ratings than
TYPSP (all ps < .05).
Phonological, Orthographic,
and Semantic Skills
Vocabulary scores were not significantly different across the
three groups. The groups differed on orthographic and pho-
nological recoding, with follow-up pairwise group compari-
sons showing that ADHDPSP scored lower on both tests
than ADHDTYPSP (p = .004 and p = .013, respectively) and
TYPSP (both ps < .001). ADHDTYPSP and TYPSP per-
formed similarly on both of these measures (both ps > .99).
Digit Span and Executive Functioning
There was a significant group difference on digit span, with
follow-up pairwise group comparisons showing that
ADHDPSP scored marginally lower than ADHDTYPSP (p =
.08) and significantly lower than TD spellers (p = .003). No
difference was seen between ADHDTYPSP and TYPSP on
digit span (p > .99).
The rate of girls with a CRT speed index in the 75th per-
centile or with one or more omissions did not differ statisti-
cally across groups. A chi-square test for commissions was
significant, suggesting an overall difference across groups.
Inspection of adjusted standardized residuals revealed that
the high rate of participants making a commission in the
ADHDPSP group was the only major contributor (i.e., >
1.96) to this overall significant result.
Graphomotor Control–Handwriting
The Coding subtest and handwriting ratings were signifi-
cantly different across the three groups. Pairwise follow-up
group comparisons showed that the two ADHD groups did
Åsberg Johnels et al. 429

Table 2. Descriptive Data of Outcome Measures in the Three Study Groups.

Group

Measure ADHDPSP ADHDTYPSP TYPSP Overall Group Comparison (χ2)

n 19 11 35
Inattention ratings (M, SD)
Teacher, CTRS-Ra 76.59 (13.08) 74.67 (12.76) 49.83 (9.75) 32.84, p < .001
Parent, FTF 13.63 (4.22) 13.00 (4.79) 1.40 (1.61) 47.52, p < .001
Hyperactivity–impulsivity ratings (M, SD)
Teacher, CTRS-Ra 69.41 (19.37) 64.11 (18.53) 50.09 (10.11) 15.18, p = .001
Parent, FTF 7.47 (5.39) 7.18 (3.25) 0.49 (0.85) 42.20, p < .001
Orthographic recoding 75.51 (13.79) 97.03 (16.43) 100.35 (12.00) 27.33, p < .001
Phonological recoding 82.49 (8.71) 96.14 (14.95) 95.74 (10.66) 17.62, p < .001
Vocabulary 8.89 (2.80) 10.00 (2.49) 10.77 (3.06) 5.53, p > .06
Digit span 7.37 (2.63) 9.45 (2.46) 9.88 (2.52) 11.12, p < .005
n, 75th percentile CRT speed (%) 6 (55) 13 (68) 15 (43) 3.25, p = .20
n, CRT commission(s) (%) 18 (95) 6 (55) 25 (71) 6.70, p = .04
n, CRT omission(s) (%) 5 (26) 5 (46) 11 (31) 1.20, p = .56
Graphomotor control (coding) 8.58 (2.67) 9.91 (2.66) 12.03 (2.49) 19.95, p < .001
Handwriting difficulties (ratings) 0.73 (0.93) 0.64 (0.67) 0.14 (0.36) 9.61, p = .008
Written expression difficulties 1.00 (0.88) 0.64 (0.81) 0.03 (0.17) 24.52, p < .001
Note:Values are means and standard deviations, except for CRT data, where the n and percentage values of presence of slow performance (75th
percentile), commissions, and omissions are reported within the study groups. CRT = Complex Reaction Time; CTRS-R = Conners’Teacher Rating
Scale–Revised; FTF = Five to Fifteen.
a
Missing data from 2 ADHDPSP group members and 2 ADHDTYPSP group members.

not differ on either of the two measures (both ps > .70). Table 3. Pearson Correlations in the TYPSP Group (n = 35;
TYPSP scored better than ADHDPSP (Coding subtest: p < below the diagonal) and the Whole Sample with ADHD (n = 30;
.001; parent ratings: p = .03) and marginally or significantly above the diagonal).
better than ADHDTYPSP (Coding subtest: p = .06; parent
ratings: p < .05). 1 2 3 4 5
1. Spelling .676** .597** .408* –.446*
2. Orthographic .550** .567** .270 –.174
Written Expression recoding
Parent ratings of written expression were significantly dif- 3. Phonological .249 .551** .411* –.130
ferent across groups. The two groups with ADHD did not recoding
differ statistically (p = .71), whereas both ADHDPSP (p < 4. Digit span .036 .162 .368* –.100
.001) and ADHDTYPSP (p = .025) were rated as having 5. CRT commission(s) –.197 –.159 .021 –.055
greater difficulties than the TYPSP. Note: Correlations are tested two-tailed. CRT = Complex Reaction Time.
*p < .05. **p < .01.

Further Analyses Using Correlation,

Regression, and Mediation Analyses
As indications of differences between ADHDPSP and
ADHDTYPSP were found on orthographic and phonologi-
cal recoding, digit span, and CRT commissions, we wished
to examine the relations between these variables and spell-
ing in greater detail. First, correlations are presented in
Table 3 for the collapsed ADHD group and for the TYPSP
separately. Moderate to strong significant correlations
were found between the measures and spelling in the group
with ADHD. Among TYPSP only orthographic choice was
significantly correlated with spelling. Note that digit span
in both groups was significantly correlated with phonologi-
cal choice, but not with orthographic choice. Next, regres-
sion analyses were run within the ADHD group with
spelling score as the dependent variable; however, because
of the small sample size we kept the number of predictors
to a minimum and constrained our analyses to those most
theoretically meaningful (see Note 1).
In a first regression, the two non-literacy-based variables—
that is, presence of CPT commission and digit span—were
430 Journal of Learning Disabilities 47(5)
entered simultaneously as independent variables. The model
accounted for a significant 33% of the variance in spelling
(F = 6.72, p = .004), and both CPT commission (β = –.41,
p = .015) and digit span (β = .37, p = .028) made a unique
contribution in predicting spelling.
In a second model, phonological choice and digit span
were entered as independent variables. The model was sig-
nificant (F = 8.57, p < .001), accounting for a total of 38% of
the variance. In this model only phonological choice made a
unique contribution (β = .48, p < .001), suggesting perhaps
that the effect of digit span to spelling was subsumed within
the contribution of lexical phonological recoding. To for-
mally test the idea that the association between digit span
and spelling is indirect via the effect of lexical phonological
recoding, a test of mediation—the Sobel test—was con-
ducted. This analysis confirmed that the association between
digit span and spelling was significantly mediated by pho-
nological recoding (z = 2.04, p = .04).
Discussion
According to the results presented here, ADHD in girls is
clearly and strongly associated with spelling difficulties.
However, the results also demonstrate that an important
minority of girls with ADHD have spelling skills on par
with girls recruited from a general school age population
(without ADHD). These “typical spellers” with ADHD had
the same marked behavioral inattentiveness and impulsivity–
hyperactivity as those with spelling problems. Thus, there
is considerable heterogeneity in the realm of spelling in
ADHD (as has previously been found with neuropsycho-
logical and reading literacy assessments in this population;
e.g., Rucklidge & Tannock, 2002). However, this heteroge-
neity did not seem obviously linked to either of the two
behaviorally defining aspects of ADHD (inattention or
hyperactivity–impulsivity).
Motivated by the lexical quality model (Perfetti & Hart,
2002), we examined phonological, orthographic, and
semantic lexical skills as a function of spelling competence.
A vocabulary definition task was used to index semantic
skills, whereas choice tasks were used to evaluate the pho-
nological and orthographic skills. These latter tests have
been used to test underlying difficulties and skills related to
literacy attainment in several different clinic groups. Most
clearly children with dyslexia or specific reading disorder
typically perform poorly on both measures (e.g., Svensson
& Jacobson, 2006), and sometimes even lower than younger
typically developing children matched on reading level
(e.g., Hultquist, 1997). In the current study the orthographic
and phonological test scores reflected the expressive spell-
ing attainment of the groups. We therefore tentatively con-
clude that there is a normal underlying spelling model in
ADHD in terms of phonological and orthographic func-
tions, as intact performance was seen on both tests in typical
spellers, whereas poor spellers with ADHD displayed the
same “normally impaired” pattern of result typically dis-
played by children with dyslexia (i.e., without ADHD). A
strength of our study is that norm-referenced tests were used,
allowing us to conclude this with some confidence even if
the study did not include a group of girls with dyslexia or
spelling problems without ADHD. On the vocabulary task,
null results were obtained. Inspection of mean scores indi-
cated, however, a somewhat lower score (albeit within the
normal range) in the poor spellers group relative to typically
developing spellers. This null result should, we think, there-
fore be followed up in future research in larger samples and
possibly also be complemented with additional oral lan-
guage measures, for example, of grammatical (Muter &
Snowling, 1997) and morphological skills (Berninger et al.,
2008).
Measures of digit span and executive functioning as
assessed with the CPT commissions were associated with
spelling difficulties. Regarding digit span, this finding is not
unique to this study but rather confirms the results by
Korkman and Pesonen (1994) who also showed that digit
span in ADHD was modulated by spelling ability, with only
those performing poorly in spelling having obvious prob-
lems. The current study further provided new information
on the relation between phonological skills and digit span in
ADHD. Specifically, many dyslexia researchers argue that
digit-span difficulties are not independent of phonological
processing problems. For instance, Ramus and Szenkovits
(2008) argued that although the underlying phonological
representations potentially are intact in dyslexia, access to
these representations is hampered because of verbal mem-
ory impairments; other researchers have proposed other
relations (e.g., Beneventi et al., 2010). Here we first found
in both the ADHD and TYP groups that digit span corre-
lated with phonological choice performance (but not with
orthographic choice), thereby confirming a distinct associa-
tion between these sets of functions. We then found that
phonological lexical skills mediated the association between
digit span and spelling in ADHD. To our knowledge this has
not been demonstrated previously.
In addition, we found that making commission on the
CPT was linked with poor spelling in ADHD. Making com-
missions might reflect difficulties in inhibitory control
(Barkley et al., 2001). Of interest, inhibition has previously
been demonstrated to be a correlate of spelling in college
students with ADHD (Semrud-Clikeman & Harder, 2011)
and also in school children with dyslexia (Altemeier, Abbott,
& Berninger, 2008). However, it is not well explicated in the
literature just how inhibition might be involved in the spell-
ing process. One possibility is that inhibition plays a role in
ad hoc error detection and monitoring (i.e., spotting and cor-
recting spelling errors; cf. Van Meel, Heslenfeld, Oosterlaan,
& Sergeant, 2007, for potentially relevant data). Another, not
mutually exclusive, possibility is that inhibitory control
Åsberg Johnels et al.
facilitates strategy execution, which sometimes is necessary
during spelling. For instance, Koziol and Budding (2009)
note that if asked to write the word receive, most people
would have no difficulties to spell the first three letters cor-
rectly in a fairly automatized manner. Thereafter, the speller
might inhibit her or his writing and instead recall and use the
strategy “i before e except after c” before continuing. Both
these possible scenarios are examples of processes where
“cognitive control” is needed, and inhibition is—together
with working memory—often seen as an integral part in this
higher level function (Barkley, 1997; Redick & Engle,
2011). As yet, however, we agree with the conclusion by
Altemeier et al. (2008) that much remains to be learned
about the relation between executive functions and writing.
With respect to graphomotor control–handwriting, diffi-
culties in this realm tended to be present in both groups with
ADHD. Thus, no support was found for the idea that
graphomotor–handwriting difficulties cause the spelling
difficulties often seen in ADHD.
Written expression and composing difficulties also co-
occurred with ADHD irrespective of spelling level. The
study did not include psychometric testing of written
expression, but relied on parent ratings. One might perhaps
question the utility of this information. Indeed, it scholars
have cautioned against “negative halo effects” in parent rat-
ings, that is, that parents of children with disabilities are
more inclined to report difficulties with just about every-
thing as they might be distressed by the overall situation of
their child (Denckla, 2002). However, this is not too worry-
ing, we think, as parents reliably rated the group with ADHD
and typical spelling (according to test results) as having no
difficulties with spelling. This result suggests that parents
are able to distinctively evaluate different aspects of the
writing ability in their daughters. The findings that written
expression might be challenging to students with ADHD
over and above that imposed by the spelling process is also
consistent with the study by Mayes and Calhoun (2006),
who found that written expression disorder was more com-
mon than spelling disorder in their clinic sample of children
with ADHD. Hence, our findings on written expression are
easily integrated with theory and some prior research. That
said, the results are clearly preliminary and in need of con-
firmation in a larger sample with a more fine-grained
approach in assessing composition skills, preferably across
several genres. Such a project would also entail test devel-
opment. Indeed, we are not aware of a single standardized
test of written expression and composition available in the
Swedish language.
While keeping in mind the associational nature of the
findings, some tentative consequences for intervention and
remediation of writing difficulties can be discussed. Several
approaches and studies of phonological and orthographic
training have proved to be efficient for supporting spelling
development (cf. Berninger, Lee, Abbott, & Breznitz, in
431
press; Høien & Lundberg, 2000; Ise & Schulte-Körne,
2010). These approaches should also be evaluated with
school-age children who have ADHD in the context of
spelling or literacy difficulties.
Recent intervention studies of school-aged children with
ADHD have indicated that specific working memory train-
ing may lead to improvements in school results, including
literacy skills (Dahlin, 2011; Klingberg et al., 2005). Holmes
et al. (2009) speculated that what is actually trained in
“working memory training” might not necessarily be “mem-
ory per se” but rather metacognition and cognitive control.
This is interesting given the observed links among spelling,
digit span, and CPT commissions and disinhibition found in
the present study.
When it comes to helping girls and boys overcome
graphomotor control–handwriting difficulties, little is
known about effective teaching strategies (but see Berninger
& Amtmann, 2003), especially if the students also have
ADHD. It is sometimes popularly proposed that the intro-
duction of computerized writing—that is, keyboarding—
might unleash hidden writing potentials in children who
struggle with handwriting, and this is supported by a wealth
of clinical evidence by the current authors. The tiny system-
atic research evidence that exists would seem to contradict
this though: Berninger, Abbott, Augsburger, and Garcia
(2009) found that children with or without handwriting and
spelling difficulties wrote faster and longer texts when writ-
ing with pen than with keyboard. More research is clearly
needed in this field.
For written expression skills there is some existing research
on promising forms of educational support for individuals with
ADHD. One approach, used by Re, Caeran, and Cornoldi
(2008), is to give procedural facilitation in the planning phase
of the writing process in the form of guide schemes. This pro-
cure made children with ADHD improve their writing in terms
of production, generation of ideas, organization, and spelling
errors. An alternative approach is strategy instruction, wherein
students learn to use cognitive or procedural strategies that
allow them to become independent and self-regulated writers.
In particular, an instructional approach called “self-regulated
strategy development” (see Mason, Harris, & Graham, 2011)
has been tested and tentatively shown to improve narrative
(Reid & Lienemann, 2006) as well as persuasive (Jacobson &
Reid, 2010) writing quality in school-aged children (all boys)
with ADHD.
We want to end by discussing some characteristics and
potential drawbacks of the current study. First, the current
study involved exclusively Swedish-speaking girls. A boy
sample or a mixed-gender sample should be used in future
research before generalizations across genders can be made.
Second, the participants were all clinically referred and not
necessarily representative of girls with ADHD in the general
population; nonetheless, we believe the sample is fairly rep-
resentative of girls who are referred to clinics for symptoms
432 Journal of Learning Disabilities 47(5)
consistent with this diagnosis (Kopp, Berg-Kelly et al.,
2010). Third, the current study did not include tests of sub-
lexical phonological awareness, for example, spoonerism or
phoneme deletion tasks. It could be argued that the phono-
logical choice test used here is not a “pure” measure of pho-
nological skills, but rather assesses processes closely related
to actual reading. Related to this is the fact that phonologi-
cal skills (perhaps irrespective of specific test used), and
also some memory skills, may be causally dependent on
literacy level, not only vice versa (Blomert & Willems,
2010; Nation & Hulme, 2011). Hence, although this study
has provided important clues on the associations between
spelling and a range of behavioral or symptomatological,
psycholinguistic, memory or executive, and graphomotor
skills in school-aged girls with ADHD, future research is
needed to determine causal relations.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article. Financial
support for this research, was provided by grants from Stiftelsen Clas
Groschinskys Minnesfond, Vilhelm och Martina Lundgrens
Vetenskapsfond II, Stiftelsen Sunnerdahls Handikappfond,
Goteborgs Lakaresallskap, Linnea och Josef Carlssons Stiftelse,
Swedish Foundation for Research in Child Neuropsychiatry,
Barnklinikens Forskningsfond, the RBU Forskningsfond, the
Swedish State under the LUA-agreement, and a grant to Christopher
Gillberg from the Swedish Science Council.
Note
1. Orthographic skills have recently been shown to be a conse-
quence rather than cause of literacy development (Deacon,
Benere, & Castles, 2012); it therefore did not seem meaningful
to enter orthographic coding as a predictor of spelling in this
cross-sectional study.
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